AmeriHealth RX Medicare prescription drug plan
Individual Enrollment Form
A
To Enroll in AmeriHealth® Rx, Please Provide the Following Information:
Please check which plan you want to enroll in:
Monthly
Premium
M AmeriHealth Rx Option I
$54.30
M AmeriHealth Rx Option II
$58.90
LAST Name:
FIRST Name:
Sex: M M M F
Birth Date:
M M D D
Middle Initial
Social Security Number:
(providing this information is optional)
M Mr.
M Mrs.
M Ms.
Home Phone Number:
Y Y Y Y MMM-MM-MMMM MMM-MMM-MMMM
MM-MM-MMMM
Permanent Residence Street Address:
City:
State:
ZIP Code:
Mailing Address (only if different from your Permanent Residence Address):
Street Address:
City:
State:
MM ZIP Code: MMMMM
Emergency Contact: _________________________________
Phone Number:
E-mail Address:
MMM-MMM-MMMM Relationship to You:
Please Provide Your Medicare Insurance Information
B
Please take out your Medicare Card to complete
this section.
Medicare
• Please fill in these blanks so they match your red,
white, and blue Medicare card
SAMPLE ONLY
Name: _______________________________________
Medicare Claim Number
Sex ___________
– OR –
• Attach a copy of your Medicare card or your
letter from the Social Security Administration or
Railroad Retirement Board.
MMMMMMMMM MM
Is Entitled To
You must have Medicare Part A or Part B (or both) to
join a Medicare prescription drug plan.
C0004_S2321_AHRx09_12 (08/08)
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Health Insurance
Effective Date
MM-MM-MMMM
(Part B) MM-MM-MMMM
HOSPITAL (Part A)
MEDICAL
7764(09/08)APPAH6
Plan Premium
Paying Your
C
You can pay your monthly plan premium by mail or Electronic Funds Transfer (EFT) each month. You can
also choose to pay your premium by automatic deduction from your Social Security Check each month.
If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of
your plan premium. If Medicare pays only a portion of the premium, we will bill you for the amount that Medicare
does not cover.
If you don’t select a payment option, you will receive a bill each month.
Please select a premium payment option:
M Receive a bill
M Electronic Funds Transfer (EFT) from your bank account each month. Please enclose a VOIDED check or
provide the following:
Account holder name:_________________________________________________________________________
MMMMMMMMM
Account type: M Checking
M Saving
Bank account number: MMMMMMMMMMMM Bank routing number:
M Automatic deduction from your monthly Social Security benefit check. (The Social Security deduction may take
two or more months to begin. In most cases, the first deduction from your Social Security benefit check will
include all premiums due from your enrollment effective date up to the point withholding begins.)
D
Please Answer the Following Questions
1. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee
health benefits coverage, VA benefits, or State pharmaceutical assistance programs.
Will you have other prescription drug coverage in addition to AmeriHealth® Rx? M Yes
M No
If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:
Name of other coverage:
ID # for this coverage:
Group # for this coverage:
______________________________ ______________________________ _____________________________
2. Are you a resident in a long-term care facility, such as a nursing home? M Yes
M No
If “yes” please provide the following information:
Name of Institution: _______________________________
Address & Phone Number of Institution (number and street): ___________________________________________
Please contact AmeriHealth Rx at 1-800-898-3492 (TTY users should call 1-877-219-5457) if you need information
in another format (Braille and audio tape) or language. Our office hours are seven days a week, 8 a.m. to 8 p.m.
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STOP
Please Read This Important Information
If you are a member of a Medicare Advantage plan (like an HMO or PPO), you may already have a prescription
drug benefit from your Medicare Advantage plan that will meet your needs. By joining AmeriHealth® Rx, your
membership in your Medicare Advantage plan may end. This will affect both your doctor and hospital coverage as
well as your prescription drug benefits. Read the information that your Medicare Advantage plan sends you and if
you have questions, contact your Medicare Advantage plan.
If you currently have health coverage from an employer or union, joining AmeriHealth Rx could affect your
employer or union health benefits. If you have health coverage from an employer or union, joining AmeriHealth Rx
may change how your current coverage works. Read the communications your employer or union sends you. If you
have questions, visit their website, or contact the office listed in their communications. If there is no information on
whom to contact, your benefits administrator or the office that answers questions about your coverage can help.
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E
Please Read and Sign Below
By completing this enrollment application, I agree to the following:
AmeriHealth® Rx is a Medicare prescription drug plan and has a contract with the federal government. I understand that this
prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare coverage.
It is my responsibility to inform AmeriHealth Rx of any prescription drug coverage that I have or may get in the future.
I can only be in one Medicare prescription drug plan at a time — if I am currently in a Medicare prescription drug plan, my
enrollment in AmeriHealth Rx will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll,
I may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment Period
(November 15 – December 31), unless I qualify for certain special circumstances, by sending a request to AmeriHealth Rx or by
calling 1-800-Medicare, 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
AmeriHealth Rx serves a specific service area. If I move out of the area that AmeriHealth Rx serves, I need to notify the plan so
I can disenroll and find a new plan in my new area. I understand that I must use network pharmacies to access AmeriHealth Rx
benefits, except under limited, non-routine circumstances when I cannot reasonably use AmeriHealth Rx network pharmacies.
Once I am a member of AmeriHealth Rx, I have the right to appeal plan decisions about payment or services if I disagree. I will
read the Evidence of Coverage document from AmeriHealth Rx when I receive it to know which rules I must follow in order to
receive coverage with this Medicare drug plan.
I understand that if I leave this plan and do not have or obtain other Medicare prescription drug coverage or creditable coverage
(as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my premium for Medicare prescription drug
coverage in the future.
I understand that if I am receiving assistance from a sales agent, broker, or other individual employed by or contracted with
AmeriHealth Rx he/she may be compensated based on my enrollment in AmeriHealth Rx. Counseling services may be available
in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug plan
options and concerning medical assistance through the state Medicaid program and the Medicare Savings Program.
Release of Information:
By joining this Medicare prescription drug plan, I acknowledge that AmeriHealth Rx will release my information to Medicare and
other plans as is necessary for treatment, payment and health care operations. I also acknowledge that AmeriHealth Rx will release
my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes
which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my
knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.
I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the
State where the individual resides) on this application means that I have read and understand the contents of this application. If
signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law
to complete this enrollment and 2) documentation of this authority is available upon request by AmeriHealth Rx or by Medicare.
Benefits underwritten or administered by QCC Insurance Company (Region 6).
Your Signature:Today’s Date:
M M D D Y Y Y Y
MM-MM-MMMM
If you are the authorized representative, you must sign above and provide the following information:
Name: _ __________________________________________
Address: _ ___________________________________________________________________________________
Phone Number:
MMM-MMM-MMMM Relationship to Enrollee: ________________________
Medicare Prescription Drug Plan Use Only
Plan ID #: _ _______________________________________
Effective Date of Coverage: ____________ IEP: ____________ AEP: ____________ SEP (type): _____________
Plan Representative/Agent/Broker Signature: _ ________________________________________________________
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